Anesthesia Processing Manual

Anesthesia Processing Manual
Important Information
The following disclaimer is applicable to all telephone inquiries and automated communications systems (i.e., telephone and fax) to Blue Cross and Blue Shield of Alabama:
The information provided is only general benefit information and is not a guarantee of payment. Benefits are always subject to the terms and limitations of the plan and no employee of Blue Cross
and Blue Shield of Alabama has authority to enlarge or expand the terms of the plan. The availability of benefits is always conditioned upon the patient’s coverage and the existence of a contract for
plan benefits as of the date of service. A loss of coverage, as well as contract termination, can occur under certain circumstances. There will be no benefits available if such circumstances occur.
Note: Please refer to our website, www.bcbsal.com, for the most current benefit and policy information.
Table of Contents
A. General Services ............................................................................................................................................................................................. 4
B. Personally Performed, Medical Direction and Supervision ........................................................................................ 5
C. Billing Requirements ................................................................................................................................................................................ 11
D. Additional Anesthesia Reimbursement.................................................................................................................................... 14
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A. General Services
Blue Cross and Blue Shield of Alabama recognizes and covers medically necessary anesthesia services
when performed by a qualified and licensed medical doctor (MD), certified registered nurse anesthetist
(CRNA) or anesthesiologist assistant (AA) as defined by a member’s specific benefit contract.
Global Services
Global reimbursement of anesthesia administration includes the following:
• Pre-anesthesia evaluation [Physicians’ Current Procedural Terminology (CPT) codes 99201-99205,
99221-99223];
• Post-postoperative visits (CPT codes 99211-99215, 99231-99233);
• Anesthetic or analgesic administration;
• Local anesthesia during surgery;
• Monitoring of electrocardiograms (EKGs), pulse breathing, blood pressure, electroencephalogram
and other neurological monitoring;
• Monitoring of left ventricular or valve function via transesophageal echocardiogram (TEE);
• Monitoring of intravascular fluids (IVs), blood administration and fluids used during cold
cardioplegia through non-invasive means; and
• Maintenance of open airway and ventilator measurements and monitoring.
Arterial lines and monitoring are no longer included in the global anesthesia fee. Bill for these services
separately using the same major/minor guidelines that are used with surgical services, when billed with
other procedures such as Swan Ganz.
Use of TEE for routine monitoring of patients undergoing cardiac and non-cardiac surgery does not
meet Blue Cross’ medical criteria for coverage. See Medical Policy #269: Intraoperative Transesophageal
Echocardiography for additional details and covered indications.
According to CPT guidelines, the reporting of anesthesia services is appropriate by or under the
responsible supervision of a physician. These services may include, but are not limited to, general,
regional and supplementation of local anesthesia or other supportive services in order to provide the
patient with optimal anesthesia care during any procedure.
Covered Services
Anesthesia services may be covered only when:
• The procedure for which anesthesia is administered is a covered service under the member’s
applicable Benefit Agreement; and
• Consultations rendered by an anesthesiologist for care, other than normal or uncomplicated care,
may be eligible for coverage if separately identifiable services were rendered. Substantiating
documentation is required for medical review of medical necessity. See Medical Policy #129:
Consultations Versus Referrals for documentation requirements.
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Non-Covered Services
Services not covered under the terms of the member’s applicable Benefit Agreement include, but are not
limited to, the following:
• Standby anesthesia – Blue Cross does not cover physicians “standing by” in anticipation of needing
general anesthesia;
• Anesthesia administered by the operating physician or surgical resident;
• Anesthesia by hypnosis or acupuncture; and/or
• Anesthesia for cosmetic surgery.
Administration of Anesthesia by Operating Physician
No additional payment will be made to an operating physician for anesthesia services rendered during
the course of performing a surgical procedure. Under the global guidelines, payment made to a surgeon
includes payment for anesthesia administered by the operating surgeon.
Consultations
Anesthesia consultation is part of the global procedure when performed on the day of or before the procedure and is not separately billable. However, there are some circumstances when a consultation is payable:
• Anesthesiologist consults with the patient for management of chronic intractable pain; and
• Anesthesiologist performs the consultation, but no anesthesia procedure is performed. For
example, time is spent in discussion with a patient, but the patient was not induced due
to complications.
Documentation Requirements
All billing must be supported by the patient’s anesthesia record.
B. Medical Direction, Supervision and Personally Performed
Medical Direction
Medical direction occurs when an anesthesiologist is involved in two, three or four concurrent anesthesia
procedures or a single anesthesia procedure with a qualified anesthetist. Payment will be determined for
the physician’s medical direction service of the allowable charge for the physician personally performing the
anesthesia services. For each anesthesia procedure, the anesthesiologist must provide the following seven
services and record each in the patient’s anesthesia record:
1. A pre-anesthetic examination and evaluation;
2. Prescribe the anesthesia plan;
3. Personally participate in the most demanding procedures of the anesthesia plan including,
if applicable, induction and emergence;
4. Ensure that any procedure in the anesthesia plan that he or she does not perform are performed
by a qualified anesthetist;
5. Monitor the course of anesthesia administration at frequent intervals;
6. Remain immediately physically present and available for immediate diagnosis and treatment of emergencies; and
7. Provide the indicated post-anesthesia care.
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If the above services are not performed by the anesthesiologist, the service is not considered
medical direction. The anesthesiologist must document in the patient’s medical record that he or she
performed the pre-anesthesia examination and evaluation. The record should also document that the
anesthesiologist provided post-anesthesia and whether the anesthesiologist was present during some
portion of the anesthesia monitoring or during the most demanding procedures, including induction
and emergence, where applicable.
When the anesthesiologist does not fulfill all of the “medical direction” requirements listed above, the
concurrent anesthesia services are considered medical supervision services, not medical direction
services.
• When an anesthesiologist is supervising more than four concurrent cases, the service should be
filed as follows: anesthesiologist – “AD” and CRNA – “QX”
• When a CRNA personally performed the services without medical direction or supervision, as
described above, the service should be filed as follows: CRNA – “QZ”
• AAs are always under the “medical direction” of an anesthesiologist
Ordinarily, an anesthesiologist should not furnish additional services to other patients while concurrently
directing the administration of anesthesia. Benefits may be provided if the anesthesiologist provides any
of the following services to other patients while medically directing the administration of anesthesia
without affecting their ability to administer medical direction:
• Addressing an emergency of short duration in the immediate area, such as:
1. Labor epidural placement and management;
2. Responding to medical emergencies or urgencies of short duration (i.e., establishing intravascular access in patient whose quality of care is reduced without it, tracheal intubation, advanced circulatory life support (ACLS) provision, etc.);
• Administering an epidural or caudal anesthetic to ease labor pain;
• Administering an epidural steroid injection or trigger point injection requested by another
physician. The epidural or trigger point injection may only be done in compliance with the 1:4
ratio. This does not include consults to diagnose and treat. The intent of allowing this practice is
enhancement of efficiency in providing these comonly requested procedures. The intent is
not to allow or encourage anesthesiologists to schedule and provide a full service chronic pain
management clinic while also concurrently attempting to provide the care to patients receiving
surgical anesthesia under his or her direction. The consult for performance of an epidural or
trigger point may serve as the second, third, or fourth concurrent case. This means that
performing limited pain services is not allowed while medically directing four concurrent
anesthetics. The anesthesiologist involved is responsible for being sure his or her ability to
respond to urgent or emergent needs in operating rooms, labor and delivery rooms, or any other
place in the hospital where responsibility may be, is not unsafely reduced at any time;
• Periodic rather than continuous monitoring of an obstetrical patient;
• Receiving patients entering the operating suite for the next surgery;
• Checking on or discharging patients from the post anesthesia care unit; and/or
• Coordinating scheduling matters.
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Medical Supervision
Medical supervision also occurs when the seven required services under medical direction are not
performed by an anesthesiologist. This might occur in cases when the anesthesiologist:
• Left the immediate area of the operating suite for more than a short duration;
• Devoted extensive time to an emergency case; or
• Was otherwise not available to respond to the immediate needs of the surgical patient.
Personally Performed Anesthesia
Determined by the following:
• Anesthesiologist personally performed the entire anesthesia service alone;
• Anesthesiologist is continuously involved in a single case involving a student nurse anesthetist; or
• Anesthesiologist and the CRNA are involved in one anesthesia case, and the service of each are
found to be medically necessary upon appeal. Documentation must be submitted by both
practitioners to support payment;
• CRNA personally performed the entire anesthesia service alone without:
1. Medical direction by anesthesiologist, and;
2. Not medically supervised by an anesthesiologist.
A CPT/Healthcare Common Procedure Coding System (HCPCS) modifier is a two-character (alpha and/or
numeric) code appended to a CPT/HCPCS procedure code to add specific meaning to a service provided.
Blue Cross requires the use of the following HCPCS Level II modifiers when filing general anesthesia
claims. Effective for dates of service on or after January 1, 2014, failure to submit one of the the modifiers
in the first position will result in returned or denied claims.
Required Modifiers used by Anesthesiologists include:
Modifier
Description
% of Allowed
Charge
AA
Anesthesia services performed personally by the anesthesiologist
100 percent
AD
Medical supervision by a physician; more than four concurrent
anesthesia procedures. (Three base units + actual time
units allowed)
65 percent
QK
Medical direction of two, three, or four concurrent anesthesia
procedures involving qualified individuals).
65 percent
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Required Modifiers used by CRNAs and AAs include:
Modifier
Description
% of Allowed
Charge
QX
CRNA/AA service with medical direction by an anesthesiologist.
35 percent
QZ
CRNA service without medical direction by an anesthesiologist.
70 percent
Note: Modifiers are also required for add-on codes 01953, and 01968-01969.
Physical Status Modifiers
Physical status modifiers distinguish between various levels of complexity of the anesthesia service
provided based on the patient’s condition and are represented by the letter P followed by a single digit.
These modifiers are required for Modified Anesthesia Care (MAC).
P1
Normal healthy patient
P2
Patient with mild systemic disease
P3
Patient with severe systemic disease
P4
Patient with severe systemic disease that is a constant threat to life
P5
Moribund patient who is not expected to survive without the operation
P6
Declared brain-dead patient whose organs are being removed for donor purposes
Note: Effective for dates of service on or after January 1, 2014, physical status modifiers do not impact
reimbursement rates. No additional units will be added for physical status.
Qualifying Circumstances
Qualifying circumstances are those factors such as extreme age, extraordinary condition of the patient,
and unusual risk factors which may affect the anesthesia services. These procedures are considered
add-on codes and would not be reported alone, but as additional procedures qualifying an anesthesia
procedure or service. These procedures must be filed with the appropriate modifier. Codes without the
appropriate modifier may be returned or rejected. Do not bill these procedures with physical status
modifiers or anesthesia minutes. An additional fee will be reimbursed based on the allowed units for each
circumstance:
99100 – Anesthesia for Patient of Extreme Age, Under 1 Year and Over 70 – 1 unit
99116 – Anesthesia Complicated By Utilization of Total Body Hypothermia – 5 units
99135 – Anesthesia Complicated By Utilization of Controlled Hypotension – 5 units
99140 – Anesthesia Complicated – 1 unit
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Additional Anesthesia Modifiers
The following modifiers should be used as secondary or tertiary modifiers only and not as the primary
modifier. These modifiers are intended to provide additional information specific to the services provided;
there will be no additional reimbursement made for these modifiers.
Modifier
Description
22
Increased Procedural Service — Per CPT Appendix A modifiers: When the work required
to provide a service is substantially greater than typically required, it may be identified
by adding modifier 22 to the usual procedure code. Documentation must support
the substantial additional work and the reason for the additional work (i.e., increased
intensity, time, technical difficulty of procedure, and severity of patient’s condition,
physical and mental effort required). Note: This modifier should not be appended to an
Evaluation and Management (E/M) service.
23
Unusual Anesthesia — Occasionally, a procedure which usually requires either no
anesthesia or local anesthesia must be done under general anesthesia because of
unusual circumstances. Unusual circumstances may be reported by adding the modifier
“23” to the procedure code of the basic service.
53
Discontinued Procedure — Under certain circumstances, the physician or other
qualified healthcare professional may elect to terminate a surgical or diagnostic
procedure. Due to extenuating circumstances or those that threaten the wellbeing of
the patient, it may be necessary to indicate that a surgical or diagnostic procedure was
started but discontinued. This circumstance may be reported by adding modifier 53 to
the code reported by the individual for the discontinued procedure. Note: This modifier
is not used to report the elective cancellation of a procedure prior to the patient’s
anesthesia induction and/or surgical preparation in the operating suite. For outpatient
hospital/ambulatory surgery center (ASC) reporting of a previously scheduled
procedure/service that is partially reduced or cancelled as a result of extenuating
circumstances or those that threaten the wellbeing of the patient prior to or after
administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC
hospital outpatient use).
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Modifier
59
73
74
Description
Distinct Procedural Service — Services with modifier 59 may be subject to review of
medical records. Under certain circumstances, it may be necessary to indicate that
a procedure or service was distinct or independent from other non-E/M services
performed on the same day. Modifier 59 is used to identify procedures/services,
other than E/M services, that are not normally reported together, but are appropriate
under the circumstances. Documentation must support a different session, different
procedure or surgery, different site or organ system, separate incision/excision,
separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily
encountered or performed on the same day by the same individual. However, when
another already established modifier is appropriate it should be used rather than
modifier 59. Modifier 25 should be used only if a more descriptive modifier is not
available, and the use of modifier 59 best explains the circumstances. Note: Modifier 59
should not be appended to an E/M service. To report a separate and distinct E/M service
with a non-E/M service performed on the same date, see modifier 25.
Discontinued Outpatient Hospital/ASC procedure prior to the administration of
anesthesia — Due to extenuating circumstances or those that threaten the wellbeing of
the patient, the physician may cancel a surgical or diagnostic procedure subsequent to
the patient’s surgical preparation (including sedation when provided, and being taken
to the room where the procedure is to be performed), but prior to the administration of
anesthesia [local, regional block(s) or general]. Under these circumstances, the intended
service that is prepared for but cancelled can be reported by its usual procedure code
and the addition of modifier 73. Note: The elective cancellation of a service prior to the
administration of anesthesia and/or surgical preparation of the patient should not be
reported. For physician reporting of a discontinued procedure, see modifier 53.
Discontinued Outpatient Hospital/ASC procedure after the administration of
anesthesia — Due to extenuating circumstances or those that threaten the wellbeing
of the patient, the physician may terminate a surgical or diagnostic procedure after the
administration of anesthesia [local, regional block(s), general] or after the procedure
was started (incision made, intubation started, scope inserted, etc.). Under these
circumstances, the procedure started but terminated can be reported by its usual
procedure code and the addition of modifier 74. Note: The elective cancellation of a
service prior to the administration of anesthesia and/or surgical preparation of the
patient should not be reported. For physician reporting of a discontinued procedure,
see modifier 53.
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C. Billing Requirements
Claim Filing
Effective for dates of service on or after January 1, 2014, Blue Cross requires claims for anesthesiologists,
CRNAs and AAs to be billed under the name and National Provider Identifier (NPI) of the provider who
actually rendered the service. Blue Cross does not recognize “incident to” billing for anesthesia services.
All providers should render services based on the scope of their particular license and requirements of
the State of Alabama. Practitioners (anesthesiologists, CRNAs and AAs) must each file for the professional
anesthesia services they performed electronically on the electronic 837 Professional 5010.
For CRNA services performed on or after January 1, 2014, services will no longer be reimbursed through
the hospital Blue Cross Cost Study. Both CRNA costs and charges should be excluded from the costs and
charges reported in the hospital Blue Cross Cost Study.
Coding
Qualified anesthesia providers may bill directly for services using CPT anesthesiology codes 00100 –
01999. While some surgical CPT codes are appropriate to use when billing anesthesia services (e.g., CPT
code 36620) the majority of anesthesia services should be billed using codes in the range of 00100 –
01999.
Base Units
The base unit is the value assigned to each CPT code and includes all usual services except the time
actually spent in anesthesia care. Pre-operative and post-operative visits are usually included. When
multiple anesthesia services are performed, only the anesthesia services with the highest base unit value
should be filed with total time for all services reported on the highest base unit value. The base units
value should never be entered in the “units” field when filing claims. Effective for dates of service on or
after January 1, 2014, Blue Cross will utilize the Centers for Medicare & Medicaid Services (CMS) base unit
values.
Anesthesia Time and Calculation of Time Units
According to CPT guidelines, anesthesia time begins when the anesthetists begins to prepare the patient
in the operating room or in an equivalent area and ends when the anesthetist is no longer in personal
attendance and the patient may be safely placed under post-anesthetic supervision.
Anesthesia time should be reported in minutes. Effective for dates of service on or after January 1, 2014,
for all Anesthesiologists, CRNAs and AAs, one unit of time will be allowed for each 15 minute increment of
anesthesia or a fraction thereof.
Reimbursement for time based anesthesia is based on the following formulas:
Anesthesia Personally Performed by Anesthesiologist or CRNA (AA or QZ Modifier)
(Base Factor + Total Time Units) x Anesthesia Conversion Factor x Modifier Adjustment = Allowance
Anesthesia Performed under Medical Direction (QK, QX and QY modifiers)
[(Base Factor + Total Time Units) x Anesthesia Conversion Factor] x Modifier Adjustment = Allowance for each provider
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Anesthesia “base unit” is the number of units assigned for the anesthetic management of surgical
procedures using nationally recognized anesthesia base value standards. Base units are automatically
calculated and should not be reported on the claim form. Blue Cross will utilize the CMS base unit values.
Anesthesia time should be submitted on the claim as total minutes. For example, one hour and nine
minutes of anesthesia time is billed as 69 minutes. Blue Cross then converts minutes into 15-minute
increments. This calculation would be four 15 minute time units and 9/15 of one unit. Total time units for
this example are 4.6.
Blue Cross recognizes that the patient must be prepared immediately prior to induction and that some
time may be spent immediately after the conclusion of the surgical procedure. Generally, no more
than one unit should be necessary to prepare the patient for post-operative transfer to the recovery
room. It is inappropriate to bill for anesthesia time while the patient is waiting in a holding area. If it is
necessary for a more extensive service to be provided, documentation must be provided in the patient’s
medical record to substantiate medical necessity. It is inappropriate to bill time units for services such
as administration of blood products or antibiotics in the holding area, when such services could be
provided in another area of the hospital or facility.
Billing Modifier Combinations
Claims for anesthesia services, must be filed using a modifier on each line of the claim. The modifiers are
specific to the provider’s specialty. Claims filed by an anesthesiologist that contains a QX or QZ modifier
on any claim line will be returned to the provider or denied. Likewise, a claim filed by a CRNA that contains AA, AD, QK or QY modifiers in any position will be returned to the provider or denied. A claim filed
by an AA may only use a QX modifier and if any other modifier appears in any position on any line, the
claim will be returned to the provider or denied. The following chart reflects the appropriate modifier, by
specialty, that should be in the first position on each line of claim filed by the provider.
Non-Acceptable Modifier Combinations:
Modifier
Deny claim when filed on the
same claim line with:
AA – Anesthesiologists
AD, QY, QK, QX, or QZ
QY – Anesthesiologists
AA, AD, QK, QX, or QZ
QK – Anesthesiologists
AA, AD, QY, QX, or QZ
AD – Anesthesiologists
AA, QY, QK, QX, or QZ
QX – CRNAs/AAs
AA, AD, QY, QK, or QZ
QZ – CRNAs
AA, AD, QY, QK, or QX
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Cancelled Anesthesia
If anesthesia is cancelled due to unforeseen circumstances; the pre-anesthetic examination and the
anesthesia services furnished may be billed and paid depending on when the anesthesia services were
terminated and whether or not the procedure is rescheduled.
• If a case was cancelled after the pre-operative examination but prior to the patient being
prepared for surgery or induction, the service may be covered at the E/M level of care rendered
(e.g., brief or limited visit) as a hospital or office visit.
• A pre-anesthesia evaluation by the anesthesiologist when the procedure is delayed less than
30-days is not eligible for coverage as a separate procedure. It is an integral part of the subsequent
anesthesia services.
• If a case was cancelled after induction of anesthesia, bill the case with the anesthesia CPT code for
the procedure that was being rendered. Add a “53” for the tertiary modifier to indicate the
discontinued procedure. Reimbursement will be based on the amount of time reported plus the
base units for the discontinued procedure.
Multiple or Duplicate Anesthesia Services
When multiple surgical procedures are performed during a single anesthesia administration, only
the anesthesia with the highest base value is reported. Reported time is the combined total for
all procedures.
When duplicate anesthesia codes are reported by the same or different provider for the same patient
on the same date of service, specific reimbursement will be based on the reported modifier. File with
appropriate modifiers.
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D. Additional Anesthesia Reimbursement
Local
Anesthesia
Reimbursement for topical anesthesia, local anesthesia, local infiltration
and/or metacarpal/digital block, is included in the basic allowance of the
surgical procedure performed. No additional reimbursement is provided.
Labor Epidurals
Anesthesia for labor epidurals are time-based services and should be billed
as total minutes.
CPT code 01967: Neuraxial Labor Analgesia/Anesthesia for Planned
Vaginal Delivery
This includes any repeat subarachnoid needle placement and drug injection
and/or any necessary replacement of an epidural catheter during labor.)
Code may be reported as a single anesthesia service.
CPT code 01968: Cesarean delivery following failed attempt at vaginal delivery
This is an add-on code and should always be reported with CPT code 01967.
CPT code 01969: Cesarean delivery followed by a cesarean hysterectomy after
failed planned vaginal delivery
This is an add-on code and should always be reported with CPT code 01967.
Anesthesia
During Delivery
CPT code 99140: This add-on code may be billed for labor ending in an urgent or
emergency cesarean delivery with four additional units.
Note: 01967 and add-on codes 01968 and 01969 require a concurrency modifier in the
first position.
Scenarios:
• For labor less than 4 hours ending in vaginal delivery : CPT code 01967
• For labor less than 4 hours ending in a cesarean delivery: CPT code 01967
and 01968
• For labor ending in an urgent or emergency cesarean delivery, CPT code 99140
may be billed with CPT code 01967 and 01968
• For labor 4 hours or more ending in a vaginal delivery: CPT code 01967 with
modifier 23
• For labor 4 hours or more ending in a cesarean delivery : CPT code 01967 with
modifier 23 and add on CPT code 01968
• For labor ending in an urgent or emergency cesarean delivery: CPT code 01967
with add-on code 01968 and 99140
Note: Payment for anesthesia administered by the delivering physician is included in the
global maternity fee.
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Anesthesia
for Burns
CPT code 01952 is the primary code for billing Anesthesia for Second and Third
Degree Burn Excision or Debridement With or Without Skin Grafting. The add-on
CPT code 01953 is not considered an anesthesia management service and should
not be reported with time. CPT code 01953 may be reported with units of service
up to a maximum of 10. This procedure will be paid from the fee schedule rather
than the anesthesia calculation with time and base units. CPT code 01952 and addon code 01953 must be filed with the appropriate modifier in the first position.
Monitored
See Medical Policy #470 MAC
Anesthesia (MAC)
Nerve Blocks
When introduction or injection of anesthetic agent is administered the anesthetic
agent is included in the payment for the actual procedure and not separately billable.
Epidural
Catheters
Intractable Pain
For control of intractable pain that is resistant to conventional forms of therapy
(i.e., physical therapy, TENS units, etc.) payment may be allowed for the placement
of a catheter. In addition, CPT code 01996 (daily management) may be billed
on a daily basis as long as an identifiable service is being rendered by the
anesthesiologist, CRNA or AA and deemed medically necessary and within
the scope of their license. CPT code 01996 is not allowed on the same day as
placement of an epidural catheter.
Patient
Controlled
Analgesia (PCA)
These services are covered separately when performed for the control of
post-operative pain and billed by an anesthesiologist, CRNA or AA within the
scope of their license. Otherwise, these services are included in the global surgery
or other medical service. The usual route of administration via a PCA pump is
through an intravenous line. When this service is provided through an intravenous
line, an anesthesiologist will be allowed four additional units for providing
management of the PCA pump. The global reimbursement covers any rate or
dosage adjustments necessary during the post-operative period. Use CPT code
01999 to report this service.
Anesthesia for
CAT Scans and
MRI Procedures
Payment can be made for anesthesia for computerized axial tomography (CAT) or
magnetic resonance imaging (MRI) scans by Blue Cross if there is documentation
supporting the medical necessity of the anesthesia such as:
• Convulsive disorders;
• Tremors of the head and body;
• Cerebral palsy, Parkinson’s Disease;
• Children too young to cooperate, and/or
• Uncooperative patient due to brain injury, mental derangement, mental
deficiency, diseases of the brains, etc.
See Medical Policy for other specific conditions.
Standby
Anesthesia
Standby anesthesia is not payable by Blue Cross.
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Frequently Asked Questions
Network
Q. Why has Blue Cross made a decision to contract with CRNAs and AAs?
Healthcare Reform Provider Non-discrimination PPACA § 1201; PHSA § 2706(a) NON-DISCRIMINATION IN HEALTH
CARE requires that group health plans and health insurers shall not discriminate against health care providers
acting within the scope of their license or certification under the laws of the state of Alabama. In order to be in
compliance, Blue Cross reviewed all provider types to ensure that providers covered under this provision could
file claims. Changes were necessary for CRNAs and AAs.
Q. If a CRNA is already enrolled with Blue Cross, does he or she need to reapply for the CRNA Network?
Yes, having a provider number and being “credentialed” for the networks are not the same thing. All providers
applying for network participation with any network must go through the same process.
Q. What is required to apply for the CRNA Network?
Providers must complete the Physician Extender Application, all supporting forms, and provide the requested
documentation. Missing forms or required documentation will slow down the credentialing process.
Q. Will the Federal Employee Program (FEP) CRNA Network remain in place?
Effective January 1, 2014, the new CRNA Network will replace any existing networks, including the FEP
CRNA Network.
Q. Will groups exclude CRNAs as eligible providers?
No, groups will no longer exclude CRNAs as eligible providers.
Claims Processing
Q. What changes are being made in claims processing?
Blue Cross will implement a process more consistent with the industry standard practice for the filing and
processing of anesthesia claims to accomodate:
• The use of modifiers to indicate medical direction or personally performed services.
• EDI edits for appropriate use of modifiers and standardization of time unit calculation.
Q. How were the services provided by CRNAs/AAs reimbursed previously?
Blue Cross traditionally reimbursed physicians for the services provided by CRNAs/AAs under an “incident to”
arrangement. Hospital-employed CRNAs/AAs were reimbursed directly by the hospital. Anesthesiologists
employing a CRNA/AA were reimbursed through the physician claim and received an extra unit for the cost of
employment and were paid on 15-minute time units. Anesthesiologists that used hospital-employed CRNAs did
not receive an extra unit and were paid on 30-minute time units.
Q. Will the anesthesiologist employing CRNAs/AAs still receive an extra unit?
Effective for services rendered on or after January 1, 2014, employing CRNAs/AAs will not result in any extra units
added to the anesthesia calculations. Time units will all be calculated based on 15-minute units.
Q. Will the anesthesiologist using hospital-employed CRNAs/AAs have 30-minute time units?
No, all anesthesia time calculations will be based on 15-minute time units.
Q. What will change for hospitals?
Beginning January 1, 2014, hospitals must remove costs for professional services of anesthesiologists, CRNAs and
AAs from their Blue Cross Cost Study. Professional services must be billed electronically on the electronic 837
Professional 5010.
Q. If Blue Cross is adopting the CMS base units for anesthesia codes, what was being used before?
Blue Cross utilized proprietary base units, many of which were the same as the CMS base units, but there were
a few differences. Utilizing the CMS base units should provide a more standardized reconciliation of
claims payment.
Q. How many codes will be affected by this change?
There are 11 CPT codes that will have a change in the base units after January 1, 2014, including: 00142, 00147,
00540, 00548, 00700, 00797, 00800, 00810, 00902, 01150 and 01440.
Q. Will Blue Cross recognize the anesthesia modifiers for medical direction?
Yes, effective January 1, 2014, appropriate HCPCS Level II modifiers are required for anesthesia claims to ensure
the proper billing of anesthesiology CPT codes 00100–01996. The edits also ensure that claims with inappropriate
modifier combinations are not accepted. The modifier must be used with add-on CPT codes 01953, 01968, 01969,
99100, 99116, 99135 and 99140. Effective June 1, 2014, modifiers are no longer required for add-on CPT codes
99100, 99116, 99135 and 99140.
Q. What about the MAC codes?
The MAC Policy #470 remains the same. The physical status modifiers must be present.
Q. What defines medical direction?
For each anesthesia procedure, the anesthesiologist must perform all of the following seven services and they
must be recorded in the anesthesia record:
1. Perform a pre-anesthetic examination and evaluation;
2. Prescribe the anesthesia plan;
3. Personally participate in the most demanding procedures of the anesthsia plan including, if
applicable, induction and emergence;
4. Ensure that any procedure in the anesthesia plan that he or she does not perform are performed
by a qualified anesthetist;
5. Monitor the course of anesthesia administration at frequent intervals;
6. Remain physically present and available for immediate diagnosis and treatment of
emergencies; and
7. Provide all the indicated post-anesthesia care.
Q. What will happen if the modifiers are not on the claims?
These edits will be specific to the provider’s specialty, and claims that do not contain the appropriate modifiers or
have inappropriate modifier combinations will be returned to the provider for correction.
Q. What are the specialty and modifier requirements?
• Anesthesiologist:
AA - Anesthesia services performed personally by the anesthesiologist
AD - Medical supervision of five or more concurrent anesthesia procedures by an anesthesiologist
QK - Medical direction (by anesthesiologist) of two, three or four concurrent procedures
QY - Medical direction of one CRNA/AA by an anesthesiologist
• CRNA/AA:
QX - CRNA/AA service with medical direction by an anesthesiologist
• CRNA:
QZ - CRNA service without medical direction by an anesthesiologist
Q. There are a number of changes with anesthesia processing. Are there any exceptions?
Though the intent is to become more standardized with CMS and other insurers, there are some exceptions that
Blue Cross had made, including:
• CPT codes 01953, 01967, 01968, 01969, 01996 and 01999 will continue to price with a set fee. This fee is
calculated using the conversion factor.
• CPT codes 99100, 99116, 99135 and 99140 used for qualifying circumstances will continue to be paid from a
fee calculated using the conversion factor.
• MAC Policy #470 will be unchanged for Blue Cross.
An Independent Licensee of the
Blue Cross and Blue Shield Association
(05-2014)